This document provides guidelines for the management of patients with mitral stenosis. It discusses initial diagnosis with transthoracic echocardiography and recommends transesophageal echocardiography for patients being considered for percutaneous mitral balloon commissurotomy. It also covers follow up care with repeat echocardiography, assessing for changes in symptoms, and determining intervention options.

1. Management of Mitral Stenosis

2. 2014 AHA/ACC guideline for the management of patients
with Mitral Stenosis
A report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines.
Management of Mitral Stenosis

3. Initial Diagnosis
• In patients with signs or symptoms of rheumatic MS, TTE is indicated to
establish the diagnosis, quantify hemodynamic severity, assess concomitant
valvular lesions, and demonstrate valve morphology (to determine suitability
for mitral commissurotomy).
• In patients considered for percutaneous mitral balloon commissurotomy
(PMBC), TEE should be performed to assess the presence or absence of LA
thrombus and to evaluate the severity of MR.
Diagnosis and Follow-up
Management of Mitral Stenosis

4. Changing Signs or Symptoms
• Patients with an established diagnosis of rheumatic MS may experience a
change in symptoms attributable to disease progression related to recurrent
episodes of rheumatic fever leading to further valve damage; progressive
narrowing of the mitral valve attributable to leaflet fibrosis and thickening;
progressive pulmonary hypertension; or worsening of concomitant MR or
other valve lesions.
• In addition, symptom status may change with no change in rheumatic MS
severity because of an increased hemodynamic load (for example, because
of pregnancy), new-onset or rapid AF, fever, anemia, or hyperthyroidism, or
hemodynamic shifts in the perioperative period of patients undergoing
noncardiac surgery.
• In such cases, a repeat TTE examination can quantify the mitral valve
gradient and area, as well as other parameters that may contribute to a
change in symptoms.
Management of Mitral Stenosis

5. Follow up
• Progressive enlargement of the RV and a rise in RV systolic pressure can be
observed, even in the absence of a decrease in mitral valve area.
• Repeat TTE at intervals dictated by valve area is an important aspect of disease
management, even in patients without symptoms.
Management of Mitral Stenosis

6. Cardiac Catheterization
• In older patients, other factors contributing to symptoms may need to be further sorted
out, such as concomitant diastolic dysfunction, LA noncompliance, or intrinsic
pulmonary vascular disease.
• Cardiac catheterization is useful in these patients to further characterize rheumatic
MS hemodynamics and etiology of symptoms, as it can measure absolute pressures
in the LV, LA, and pulmonary circulation at rest and with exercise.
Exercise Testing
• In patients with rheumatic MS and a discrepancy between resting
echocardiographic findings and clinical symptoms, exercise testing with
Doppler or invasive hemodynamic assessment is recommended to evaluate
symptomatic response, exercise capacity, and the response of the mean
mitral gradient and pulmonary artery pressure.
Management of Mitral Stenosis

7. Anticoagulation with a VKA is indicated in patients with rheumatic MS and
1) AF
2) prior embolic event
3) LA thrombus
In patients with rheumatic MS and AF with a rapid ventricular response, heart
rate control can be beneficial.
In patients with rheumatic MS in normal sinus rhythm with symptomatic
resting or exertional sinus tachycardia, heart rate control can be beneficial to
manage symptoms.
Medical Therapy
Management of Mitral Stenosis

8. In symptomatic patients (NYHA class II, III, or IV) with severe rheumatic MS
(mitral valve area ≤1.5 cm2, Stage D) and favorable valve morphology with less
than moderate (2+) MR∗ in the absence of LA thrombus, PMBC is
recommended if it can be performed at a Comprehensive Valve Center.
In severely symptomatic patients (NYHA class III or IV) with severe rheumatic
MS (mitral valve area ≤1.5 cm2, Stage D) who
1) are not candidates for PMBC,
2) have failed a previous PMBC
3) require other cardiac procedures
4) do not have access to PMBC, mitral valve surgery (repair, commissurotomy,
or valve replacement) is indicated.
Management of Mitral Stenosis
Intervention for Rheumatic Mitral Stenosis

9. • In asymptomatic patients with severe rheumatic MS (mitral valve area ≤1.5
cm2, Stage C) and favorable valve morphology with less than 2+ MR in the
absence of LA thrombus who have elevated pulmonary pressures
(pulmonary artery systolic pressure >50 mm Hg), PMBC is reasonable if it
can be performed at a Comprehensive Valve Center.
• In asymptomatic patients with severe rheumatic MS (mitral valve area ≤1.5
cm2, Stage C) and favorable valve morphology with less than 2+/ MR∗ in the
absence of LA thrombus who have new onset of AF, PMBC may be
considered if it can be performed at a Comprehensive Valve Center.
Management of Mitral Stenosis

10. • In symptomatic patients (NYHA class II, III, or IV) with rheumatic MS and an
mitral valve area >1.5 cm2, if there is evidence of hemodynamically
significant rheumatic MS on the basis of a pulmonary artery wedge
pressure >25 mm Hg or a mean mitral valve gradient >15 mm Hg during
exercise, PMBC may be considered if it can be performed at a
Comprehensive Valve Center.
• In severely symptomatic patients (NYHA class III or IV) with severe
rheumatic MS (mitral valve area ≤1.5 cm2, Stage D) who have a suboptimal
valve anatomy and who are not candidates for surgery or are at high risk for
surgery, PMBC may be considered if it can be performed at a
Comprehensive Valve Center.
Management of Mitral Stenosis

11. In severely symptomatic patients (NYHA class III or IV) with severe MS
(mitral valve area ≤1.5 cm2, Stage D) attributable to extensive mitral
annular calcification, valve intervention may be considered only after
discussion of the high procedural risk and the individual patient’s
preferences and values.
Management of Mitral Stenosis
Intervention for Non Rheumatic Mitral Stenosis